Information About Employer Name of Employer: * Type of Entity: * Proprietorship Limited Liability Company Limited Liability Partnership Partnership Address of Employer's Home Office: * Agreements by Individual. I previously made a nonelection of workers’ compensation or employers’ liability coverage. Statement 1 Agreement: * I understand that by signing this termination, I will terminate the nonelection of coverage. Statement 2 Agreement: * I also understand that after signing and filing this termination, my status will be the same as if the nonelection of coverage had not been made. Statement 3 Agreement: * I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. Statement 4 Agreement: * Individual Information Date: * Year20212022202320242025 Year MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Full Name of Individual: * Email: * City of Residence: * County of Residence: * State of Residence: * Full Name of Witness 1: * Full Name of Witness 2: * Signed Signed Indication: * By selecting the "Signed" button above, I hereby sign this form and, in doing so, swear or affirm that: The information I have provided is true and correct to the best of my knowledge; I am a proprietor, limited liability company member, limited liability partner, or partner of the employer; I am signing this form in front of the two witnesses I have identified; and Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the employer. I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22. Termination by Employer. The employer terminates the prior nonelection the employers’ liability coverage. Termination Agreement: * Employer Information Full Name of Authorized Agent: * Email of Authorized Agent: * Relationship to Employer of Authorized Agent: * City of Residence: * County of Residence: * State of Residence: * Full Name of Witness No. 1: * Full Name of Witness No. 2: * Signed Signed indication: * By selecting the "Signed" button above, I hereby sign this form and swear or affirm that: The information I have provided is true and correct to the best of my knowledge; I am authorized to terminate the rejection of workers’ compensation or employers’ liability coverage on behalf of the corporation. I signed this form in front of the two witnesses I have identified; and Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the employer. I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22. Leave this field blank Submit
